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74. Quamany OF DEFECTS AND SiscuosEs (Lan deagneess wih Hen numbert)
78. RECOMMENDATIOND—FUNTHER BPECIALIST ELAMINATIONS InOIcATED (Specify)
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SIGMATUAL
OO. TYPED OR PAlmTED NAME OF PuYeiciAN
Siematuar
1. TYPED OR PRINTED WAME OF DENTIST OR PHYSICIAN Limdicate whack)
SIGNATURE
82. TYPED OR
SIGNATURE
CARL L. HANSEN, bt Col,USAF,MO,7S
PRINTED MAME OF
REVIEWING OFFICER OR APPROVING AUTHORITY
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NUMBER OF AT+
TACHEO SWEETS
4, . GOVERNMENT PRINTING OFFICE: LOET O—askane
BESTAVAILABLE COPY